Heath Ledger, celebrity overdoses and the danger of combining prescriptions

What do Heath Ledger, Elvis Presley, Anna Nicole Smith, Judy Garland and Marilyn Monroe have in common? They all died of accidental prescription drug overdoses. And those are just a few of the most famous cases. There are lots more cases involving lesser known stars, and, of course, most tragic are the thousands of “average” people who die each year due to accidental prescription drug overdoses. Exact numbers are hard to come by because of the difficulty in separating out prescription drug overdoses from those involving street drug overdoses (e.g., heroin, cocaine, etc), but one study found that deaths involving prescription opioid analgesics increased from roughly 2900 in 1999 to 7500 in 2004, a 160% increase. That study was done by Dr. Leonard Paulozzi of the Centers for Disease Control who stated that “[B]y 2004, opioid painkiller deaths numbered more than the total of deaths involving heroin and cocaine. For the first time, it became apparent that prescribed controlled substances were driving the upward trend in drug poisoning mortality.”

So what exactly are opioid analgesic painkillers and what other drugs are involved in accidental prescription drug overdoses? Moreover, what can you do to avoid problems for yourself and your loved ones? The opioid drugs are narcotic painkillers with names like Vicodin, Oxycontin, codeine, hydrocodone, oxycodone, hydromorphone, morphine, fentanyl, methadone and many others. They all have several characteristics in common; namely, that they all reduce pain, all depress the central nervous system (CNS), particularly the part responsible for breathing, all are addictive and all lead to tolerance (meaning that over time you need to take more to get the same effect).

But opioid analgesics are only part of the problem because they can, and often are, combined with other medications that can have similar CNS depressant activities. The most common of these would be tranquilizers and barbiturates. Tranquilizers include the benzodiazepine drugs such as Valium (diazepam), Xanax (alprazolam), Ativan (lorazepam), Klonopin (clonazepam) and Restoril (temazepam). They also include the major tranquilizers such as Thorazine (chlorpromazine), Haldol (haloperidol) and Compazine (prochlorperazine). All tranquilizers tend to depress the CNS but they rarely cause problems when used by themselves (the problems that we are talking about almost always involve a combination of drugs from a number of different categories).

While not used as frequently today, barbiturates are powerful CNS depressants, which, like opioids, can cause overdoses even when used alone. These include Seconal (secobarbital), Nembutal (pentobarbital) and Amytal (amobarbital). These drugs are often used as sedatives, meaning that they can put you to sleep. All CNS depressants have the similar capacity to put you to sleep. Therefore, to this list of drugs, we must also add the sedative antihistamines. Most people know that antihistamines have a side effect of making you drowsy. The most common of these is Benadryl (diphenhydramine). Some sedating antihistamines are marketed as sleep aids such as Sominex (diphenhydramine – yes just like Benedryl) and Unisom (doxylamine).

Now on top of all of these prescription and over-the-counter drugs, we must add in alcohol, a classic CNS depressant, which makes you sleepy and can easily kill you if taken in large enough quantities (it can kill you acutely, from drinking too much at once, or chronically, from drinking too much over a long period of time). In terms of accidental drug overdoses, we’re talking about the acute effects of drinking alcohol in combination with taking other CNS depressants.

Unfortunately, there are no guidelines that could be given to easily tell you how much of what you could take that would be safe. There are just too many factors involved from the number of different drugs, their varying doses, to your particular body chemistry and your particular tolerance for each of the various drugs, all mixed in with how much alcohol you might have consumed, over what time period and whether, and how much, food you might have eaten along with taking the various medications.

So what’s the bottom line? What can you do to protect yourself? First of all, you need to know exactly what medications you have and what they are. You may have medications prescribed by a variety of doctors, none of whom may know what the other is prescribing (and don’t forget that dentists can prescribe most, if not all of these drugs too). If you use one pharmacy, they can give you a list of all the drugs you have and can also explain what they are and which could be potential problems when combined. For example, combining a narcotic (or two), with a tranquilizer (or two), with an antihistamine gives you the cocktail of six drugs that killed Heath Ledger (Vicodin and Oxycontin = two narcotics; Valium, Xanax and Restoril = three tranquilizers and Unisom = one sedating antihistamine). The only thing missing from this mix that would have made it even more likely to have been fatal is alcohol.

Almost all prescription vials come with little stickers that tell you what drugs you shouldn’t combine them with. Problem is that very few people read these. Very few people really understand the drugs they take. Many people spend far more time reading food labels than they do drug labels. There’s a tendency for many people to think that if it was prescribed it’s ok to take. Regardless of whether the prescriptions came from different doctors and regardless if they actually know what they are taking. Compounding this is that all of the drugs involved impair one’s judgment. You may forget how much or how many of which drugs you’ve already taken. And if you’ve had a few drinks that can add to the problem; before you know it you’ve taken one or two from column A, one or two from column B, another from column C and rounded it out with a few stiff drinks – a very dangerous combination.

Knowledge is power: Know what drugs you have, how they work and whether they are CNS depressants. Moderation is key: Usually this means following directions, not taking more than what was prescribed, and not using your medicine chest as a buffet. Finally, alcohol is often the final straw, making an otherwise dangerous combination a fatal one.

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ABOUT THE AUTHOR

Ed Zimney, MD

Ed is a physician with more than 30 years of experience. He’s held positions in drug advertising review, drug safety surveillance, medical information and marketing with several bio/pharmaceutical companies.

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